Download Injections of Mineral Oil - American Journal of Neuroradiology

CASE REPORT
S. Kathuria
P.-L. Westesson
Diffuse Lipogranulomatosis Involving Soft Tissues
of the Head and Neck due to Multiple SelfInjections of Mineral Oil
SUMMARY: We describe imaging findings of a 45-year-old man with a 6-month history of gradually
increasing diffuse swelling of the neck. CT showed diffuse thickening and infiltration of the superficial
and deep soft tissues bilaterally. On further investigation of his history, the patient stated that he had
injected mineral oil into his neck to clean out his body from drugs. Biopsy results showed multinucleated giant cells and inflammatory infiltrates confirming the diagnosis of lipogranulomatosis.
W
e report the characteristic imaging appearance of lipogranulomatosis predominantly involving the head
and neck region following self-injection of mineral oil in the
neck. To our knowledge, the predominant involvement of the
head and neck region has not been previously reported in the
radiology literature.
Case Report
A 45-year-old African American man with a 16-year history of human
immunodeficiency virus (HIV), diabetes, and schizophrenia presented with gradually increasing diffuse swelling in the neck for 6
months. He had not seen any physician in the last 6 years and had not
been taking any medication during this period. One month previously, he was seen in an emergency department at an outside facility
for scrotal swelling and was advised to follow up at the HIV clinic at
our hospital. He had been on medication for schizophrenia for a brief
period many years before. He had a history of smoking and cocaine
abuse but denied any such use for the last 4 years.
On clinical examination, large swellings were noticed in the bilateral supraclavicular and submandibular regions. There was no tenderness or any evidence of cellulitis. Also noticed was induration of
the lower portion of the anterior abdominal wall skin extending into
the pubic area and scrotum with a peau d’orange appearance. The
primary consideration was matted lymphadenopathy, likely secondary to tuberculosis or Mycobacterium avium intracellulare. He was
then referred for CT scanning of the neck and abdomen.
CT images through the neck showed diffuse thickening of the
superficial and deep soft tissue bilaterally with a characteristic infiltrative process and multiple locules of macroscopic fat deposits. The
bilateral sternocleidomastoid muscles were especially diffusely prominent with similar infiltration (Fig 1A). Similar but less extensive
changes were also seen in chest wall, anterior abdominal wall, scrotum, and gluteal muscles (Fig 1B). On the basis of the characteristic
imaging findings, the diagnosis of lipogranulomatosis was suggested.
On further questioning, the patient revealed that he believed his
HIV disease was most likely obtained from intravenous drug abuse.
He then started injecting mineral oil into his neck and abdomen to
clean out his body from drugs. It was only after these injections that he
noticed the gradually progressive swelling, especially in the neck and
scrotum.
Received April 23, 2008; accepted May 1.
From Department of Imaging Sciences, the Division of Diagnostic and Interventional
Neuroradiology, University of Rochester Medical Center, Rochester, NY.
Please address correspondence to Sudhir Kathuria, MD, Johns Hopkins University, Radiology B-100, 600 N Wolfe St, Baltimore, MD 21230; e-mail: [email protected]
DOI 10.3174/ajnr.A1192
1908
Kathuria 兩 AJNR 29 兩 Nov-Dec 2008 兩 www.ajnr.org
Fig 1. A, Axial CT image shows diffuse thickening and infiltration of deep soft tissues with
multiple locules of fat. There is involvement of the bilateral sternocleidomastoid muscles.
B, Axial CT image shows similar but less extensive involvement of the anterior abdominal
wall and gluteal muscles.
Subsequent skin biopsy showed multinucleated giant cells and
inflammatory infiltrates of histiocytes and lymphocytes that have a
particular tropism for connective and adipose tissue, confirming the
diagnosis of lipogranulomatosis due to mineral oil injection.
Discussion
The first reported subcutaneous injection of exogenous lipids
goes back to 1899, when Robert Gersuny from Vienna injected
mineral oil to correct the absence of a testicle in a patient who was
castrated for tuberculous epididymitis.1 “Sclerosing lipogranuloma” is a term applied to a complication of this practice in which
injected oil elicits a marked granulomatous reaction with prominent fibrosis. Similarly, paraffin-induced sclerosing lipogranuloma is a well-known complication after intradermal injection of
paraffin in dermatology and cosmetic and endonasal surgery.2
Although this complication has been described as a localized process occurring mainly in the scrotal area and regional lymph
nodes, few studies have documented systemic manifestations.3
Diffuse lipogranulomatosis with similar radiologic and pathologic features can also be seen as extraskeletal manifestations of
Erdheim-Chester disease and Farber disease. However, these diseases predominantly involve the skeletal system.4
Although physicians have stopped the practice of oil-injection
therapy, some laypersons continue to subject themselves to the
risk of the disfiguring complication of lipogranulomatosis. There
have been many reports of such complications involving the genital area, with a few involving the abdominal wall and breast.5,6 In
the present case, there was predominant involvement of the neck
due to self-injection of mineral oil in that area. Recognition of the
characteristic imaging appearance can help physicians reach the
correct diagnosis and appropriate management. This case also
illustrates the tendency of patients to conceal the history of self-
injection of foreign bodies and associated psychological
problems.
References
1. Glicenstein J. The first “fillers,” Vaseline and paraffin: from miracle to disaster. Ann Chir Plast Esthet 2007;52:157– 61
2. Witschel H, Geiger K. Paraffin induced sclerosing lipogranuloma of eyelids
and anterior orbit following endonasal sinus surgery. Br J Opthalmol
1994;78:61– 65
3. Rollins CE, Reiber G, Guinee DG Jr. Disseminated lipogranulomatosis and
sudden death from self-administered mineral oil injection. Am J Forensic Med
Pathol 1997;18:100 – 03
4. Tan APA, Tan LKA, Choo IH. Erdheim-Chester disease involving breast and
muscle: imaging findings. AJR Am J Roentgenol 1995;164:1115–17
5. Motoori K, Takano H, Ueda T, et al. Sclerosing lipogranuloma of male
genitalia: CT and MR images. J Comput Assist Tomogr 2002;26:138 – 40
6. Rosen T, Chen M. Factitious disease of the breast of a male due to injection of
liquid plastic. Int J Dermatol 2001;40:743– 46
HEAD & NECK
CASE REPORT
AJNR Am J Neuroradiol 29:1908 – 09 兩 Nov-Dec 2008 兩 www.ajnr.org
1909